Natasha Richardson's fatal descent began when she suffered a rare bout of "talk and die syndrome" after falling on a Quebec ski hill with limited access to head-trauma specialists.
Brain-injury experts say victims of the infrequent syndrome, which masks head injuries, are often conscious after hitting their heads and lucid enough to deem themselves unhurt, as Ms. Richardson did this week, laughing off her tumble on a beginners hill at Mont Tremblant and declining an ambulance. Victims can appear healthy even though they require medical attention and, in some cases, are on the brink of death.
"You can't drag them screaming to the hospital," said Charles Tator, a University of Toronto neurosurgeon who emphasized that talk and die syndrome is an infrequent occurrence in brain-injury cases. Still, he said: "Every health-care professional, paramedic and ski patroller knows about this phenomenon. That's why you never allow a head-injured person to be alone."
Mont Tremblant employees told The Globe and Mail they monitored the actress after she returned to her hotel after the fall and summoned an ambulance when her condition began to deteriorate.
An autopsy revealed yesterday that Ms. Richardson sustained a brain-killing clot called an epidural hematoma. Although severe, epidural hematomas can be difficult to detect at the outset.
"I have had the privilege of saving many lives during my career in just this situation, where somebody bangs their head, has a lucid interval, has a blood clot, and is brought immediately for attention," said Dr. Tator, who is also the founder of ThinkFirst, a non-profit organization for the prevention of brain injury.
As the circumstances around Ms. Richardson's death have become more clear, they have prompted much hand-wringing at resorts, where officials feel there are limits to the amount of safety precautions and medical attention they can compel guests to accept.
"It gets to be a difficult call, particularly when the guest insists that they go home ... and don't take us up on the offer to see someone," said Brian Leighton, safety manager at the Whistler Blackcomb resort in British Columbia. "If the patients are conscious and able to make these decisions on their own, we can't force them onto a spine board or into an ambulance."
In the absence of legal regulations requiring skiers to wear helmets - resorts can suggest guests wear protective headgear but cannot ban adults who refuse - head injuries are difficult to prevent.
"People fall down on ski hills all the time," said Doug Firby, a spokesman for Sunshine Village Ski and Snowboard Resort in Banff, Alta. "Some of them bang their heads. I can't imagine a scenario in which you could actually force all those people to go to hospital."